Assess Your (or your child’s) Behavioral Indicators

At Crossinology’s Learning Enhancement Center, all clients or their parents or guardians are asked to complete a confidential behavioral self-assessment. This self-assessment helps the practitioner identify the specific nature of the learning difficulty or other brain integration problems.

There are 51 questions including contact information so we may follow up with you with your results. Please complete all questions and submit the assessment by clicking on the Request Appointment Button. You will be redirected to the next page with further instructions.

How to Complete the Assessment:

For each behavior rate the experience of the person you are seeking treatment for on a 5-point scale:

  1. Always
  2. Often
  3. Sometimes
  4. Rarely
  5. Never

Required fields are marked *

1.Accident prone *
2.Allergies (feels tired or hyperactive after eating) *
3.Clumsy *
4.Daydreams excessively *
5.Difficulty budgeting time *
6.Poor organizational skills *
7.Difficulty concentrating *
8.Difficulty focusing eyes *
9.Difficulty following directions *
10.Difficulty telling time *
11.Dizziness/vertigo/balance problems *
12.Eye strain/rubs eyes a lot *
13.Fear of speaking in front a group *
14.Trouble remembering directions *
15.Trouble remembering months of the year *
16.Trouble remembering names *
17.Trouble remembering right/left *
18.Trouble remembering times tables *
19.Trouble differentiating colors *
20.Headaches *
21.Inappropriate drowsiness *
22.Letter/number reversal *
23.Lies *
24.Mood swings *
25.Over or underactive *
26.Poor eye-hand coordination *
27.Poor reading comprehension *
28.Poor reading skills *
29.Poor balance *
30.Poor spelling *
31.Poor arithmetic *
32.Rests head on arm while working *
33.Short attention span *
34.Slow in completing work *
35.Stops in the middle of a game *
36.Test or performance anxiety *
37.Timid/shy *
38.Doesn’t read for pleasure *
39.Impatient/restless/fidget *
40.Impulsive *
41.Lack of confidence *
42.Procrastinate/projects incomplete *

Age of person being assessed

Indicate any previous diagnosis by health professional

If yes, please describe

If yes, please describe.

What else would you like us to know?

Valid email where we can contact you with your results.

Valid phone number where we can contact you about your results.

First name of person completing assessment

Last name of person completing assessment

If assessment is of a minor child, what is their first name?

What state or region are you located?

The monthly amount you spend for medications or other treatments for ADD/ADHD/Dyslexia, etc.

Monthly spending for tutors, special schooling or accommodations for learning disabilities

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